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The first step in reforming the emergency medical system is to reduce its inappropriate use by patients who could safely be seen elsewhere. For example, growing numbers of uninsured Americans frequently lack regular primary care, and the ED often fills the gap. Covering the uninsured for non-emergent care-if done correctly-is an essential element of emergency medical reform and would certainly help to reduce the strain on the system. Patients would then be more likely to receive regular care (including preventive services), have less need for the ED, and avoid costly hospital admissions.

The data indicate that simply moving the uninsured into public programs such as Medicaid and SCHIP might not solve the ED demand crisis and could even exacerbate the problem. According to a recent National Hospital Ambulatory Medical Care Survey, patients with Medicaid as the expected source of payment used hospital emergency departments in 2004 at nearly twice the rate of the uninsured and at four times the rate of the privately insured. Moreover, more ED visits by Medicaid and SCHIP patients (35.7 percent) were classified as non-urgent or semi-urgent than were visits by self-paying patients (23.7 percent).<39>

The number of Medicaid-eligible patients who initially present to the emergency department as uninsured and are eventually converted to Medicaid is unknown, but it is not likely to be large enough to have any significant effect on the data reported in the NHAMCS study.<40> However, a major cause of these disparities is probably the lack of a sufficient number of primary care doctors available to Medicaid patients. This is likely a natural response to Medicaid's very low physician reimbursement rates in many states.

Thus, the most effective way to reduce inappropriate ED utilization is to institute sound "premium support" programs that would enable Medicaid patients to purchase quality private health insurance coverage with better access to care. The right policy is to integrate the working uninsured population and non-disabled Medicaid and SCHIP beneficiaries into a reformed private health insurance market.

At the state level, legislators could also create premium support programs for private health insurance for low-income individuals and families and combine this with a new statewide market in which employers could make defined contributions to their employees' health insurance through a health insurance exchange, securing portability and personal ownership of health coverage.<41> This would not only eliminate gaps in health care coverage, but also ensure continuity of care.

Beyond Medicaid changes and state market reforms, Congress could enact a universal tax deduction for health insurance, as recommended by President George W. Bush, which would allow individuals and families to purchase personal and portable health insurance.*<[/i>42] For lower-income persons, Congress could also enact a generous individual health care tax credit program, particularly for those who do not and cannot get health insurance through the workplace. Such a program, with a family tax credit of up to $4,000 annually, is embodied in the Tax Equity and Affordability Act (S. 397 and H.R. 914), sponsored by Senator Mel Martinez (R-FL) and Representative Paul Ryan (R-WI).<43>

Private health plans possess the right set of economic incentives to coordinate patient care in ways that reduce costs and improve outcomes, including limiting patient ED use to true emergency situations.

"Could a deal have been reached? Who knows? But we do know that the gap between this plan and traditional Republican ideas is not very big. The Obama plan has a broad family resemblance to Mitt Romney's Massachusetts plan. It builds on ideas developed at the conservative Heritage Foundation in the early 1990s that formed the basis for Republican counter-proposals to Clintoncare in 1993-1994."